Caution: Don’t Get Caught with Ketones

Ketoacidosis is an extremely serious diabetic complication that can lead to coma and even death. Unfortunately it is also fairly common. The good news, however, is that with proper care and an eye towards prevention, this costly and dangerous complication can be avoided.

What Is Ketoacidosis?

When there isn't enough insulin present for the metabolism of glucose, or when insufficient food has been eaten to satisfy energy requirements, the body burns fat for energy. Ketones are toxic, acidic byproducts of this process.

Ketones are normally processed by the kidneys and excreted in the urine. But when more ketones are produced than the kidneys can handle, they can build up in the blood and lead to a dangerous condition known as diabetic ketoacidosis (DKA).

Ketoacidosis raises the acidity of the body, which leads to "a cascade of problems throwing off a number a parameters in the body," says Cindy Onufer, RN, MA, CDE, the diabetes research and clinical care coordinator at Oregon Health Sciences University.

Ketoacidosis rarely occurs in people with type 2 diabetes, who usually do not suffer from insufficiency of insulin, but is of great concern to those with type 1 diabetes. In fact, ketoacidosis is the number one cause of hospitalization for children with known diabetes in the United States.

However, these hospitalizations are completely preventable if a urine ketone test is done and a care provider is called when indicated, says H. Peter Chase, MD, with the Barbara Davis Center for Childhood Diabetes in Denver, Colorado.

Timely testing and prevention are of utmost importance as the condition can cause coma and death if proper treatment is not administered quickly. Higher ketone levels are a warning sign that your diabetes is out of control or that you may be in danger of ketoacidosis.

Ketones are usually present in the urine for at least four hours before the body's total acidity is increased. The prevention of ketoacidosis relies on detecting changes early, when ketones are present, but before they get a chance to build up to dangerous levels.

Causes

High sugars are a symptom of insufficient insulin for people with type 1 diabetes, but it's the lack of insulin that occasions ketones, not the high sugars. Prolonged or excessive high sugars should, however, lead one to test for the presence of ketones.

Ketones can also present themselves in the absence of glucose. If you have too much insulin or too little food, your body turns to fat for energy. In this case ketonuria (ketones in the urine) may be accompanied by hypoglycemia.

Exercise and stress also demand energy and can lead to fat breakdown and ketone production if there isn't enough glucose on hand. Stress hormones, like adrenaline and glucagon, also cause fat breakdown when released.

Illness is also a major contributor to ketone production. The high demands of fighting infection coupled with insufficient insulin can cause the body to burn stored fat as well. Vomiting also throws off glucose levels and metabolism, and it may lead to ketoacidosis as well.

In sum, your body can produce ketones when blood sugars are high or low, and is especially prone to ketonuria when you are ill.

Urine Testing Products

Products to test ketones are available without prescription in pharmacies, under the names Ketostix and Chemstrip K. Foil-wrapped strips or vials of strips are available in different quantities, and if your pharmacy does not have the particular product you prefer, ask your pharmacist to order it. Ketone testing products should be covered under your medical plan as an item necessary to maintain good self care.

The foil wrapped products do not expire until after two or three years, while an opened vial expires after six months as it is subject to moisture and other factors. After six months, results will be unreliable. Having the unexpired, foil-wrapped strips on hand is preferable over having to look for an open pharmacy in the middle of the night when someone is in need of a ketone check due to illness.

Products that test glucose in the urine as well as ketones (Keto-Diastix and Chemstrip uGK) are also available. Glucose is now more reliably tested with meters, however, so there is no need to pay more to test glucose in the urine, except when meters are not available. Urine ketone readings, unlike urine glucose tests, remain an important part of monitoring diabetic control according to ADA position statements.

Whichever urine testing product you choose, keep these products in the home and take them along when you travel – you never know when that odd virus might cause serious trouble. A word of caution – the test areas of Chemstrips are toxic so avoid touching the strip areas and keep the products away from young children.

How to Test

A ketone test strip should be immersed briefly in the urine, then after a specified time, the resulting color change is compared to a chart. Timing is important. Use a watch to read the ketones at exactly the designated time (15 seconds to two minutes, depending on the product). Hold the strip close to the color swatch and match carefully. Do not record color change that occurs after the specified time.

If the urine is passed into a cup, a partner, rather than the ill person, can objectively time and observe for color changes. Small disposable paper cups can be kept in the bathroom for this use.

Children in diapers can be tested by pressing a test strip against the wet diaper or by placing cotton balls into the diaper, catching urine to be squeezed out later onto a strip.

All tests should be performed within an hour of specimen collection. Record the times and results of tests in a log book so they are not forgotten, especially if you will be contacting your health care provider.

When You Should Test

According to ADA and Joslin Diabetes Center guidelines, you should test for ketones if you have high sugars (over 240 mg/dL) for two tests in a row. For this reason some blood sugar meters have built-in alerts to check ketones when sugars are elevated. For example, the One Touch Profile meter by LifeScan gives a "Check Ketones" and "See Your Doctor" message when the meter registers a blood sugar reading over 240 mg/dL, notes Dave Detmers, marketing communications manager for LifeScan.

A ketone test should also be done when blood sugars are over 300 mg/dL before exercise. Do not exercise if ketones are present, because increased physical activity may worsen the condition.

Authorities such as the Joslin Diabetes Center also recommend testing during illness, infections or injuries as they can all alter the normal course of metabolism. Test for ketones every four to six hours during these times, or any time you feel sick.

See "Danger Signs" for a list of symptoms of ketoacidosis.

Other Times to Test

If you have recently been diagnosed with diabetes, you may have ketones present. Some authorities recommend checking twice daily for the first two weeks after diagnosis, and more frequently if you test positive for ketones. After the second week, routine testing can be discontinued.

People who take only one insulin injection a day can also test for ketones to determine whether their insulin is lasting a full 24 hours. A routine morning urine ketone test will show whether or not insulin is inhibiting fat breakdown as it should.

To safeguard the health of mother and baby, pregnant diabetic women should test for ketones each morning before breakfast and at any time blood sugar tests are over 180 mg/dL.

Rebounding

There is also a nighttime phenomenon known as rebounding, also called the Somogyi reaction. You might suspect this if you are experiencing variable high and low blood sugars in the morning, headaches on waking or night sweats. This may be a sign that you have had a low blood sugar in the night, followed by "rebounding."

In response to this nighttime hypoglycemia, the body produces the hormones epinephrine and glucagon that raise blood sugar. This also can result in ketones in the urine.

If you suspect rebounding, check blood sugars during the night, between midnight and four a.m. An adjustment in the bedtime snack or a reduction in insulin dose may be called for.

Treatment

If you find only small or trace levels of ketones after testing, drink a glass of water every hour to dilute the ketones and test your blood sugar every three hours. If ketone levels are not going down, call your doctor. Often your care provider can tell you what to do over the phone, including providing prescriptions to control vomiting if that is contributing to, or resulting from, your ketones.

Extra insulin and fluids are needed to clear ketones. As much as an extra 20 percent of the total daily insulin dose may be needed if ketones levels are high. The extra insulin may seem like a large dose, but ketones block the body's normal sensitivity to insulin.

The administration of insulin turns off ketone production as well as lowering blood sugar levels. The exact extra dose amount should be discussed with a health care provider well in advance of the onset of an illness.

If your blood sugar drops but ketones are still present, drinking sugary soda or juices may be an additional help to combat ketoacidosis, as juice helps replace some of the salts lost in the urine. Orange juice and bananas, in particular, can help to replace potassium that is often lost when ketoacidosis begins.

If moderate or large ketone levels are present, especially with the above mentioned "danger sign" symptoms, call your doctor immediately or go to the nearest emergency room.

Admission for ketoacidosis usually means you will go to an intensive care unit. Intravenous lines are usually put in both arms and sometimes the feet. A heart monitoring machine is also used. The cost for this level of care can range from $5,000 to $10,000.

It is possible, with knowledge and good care, to never have an episode of ketoacidosis. The key to ketones is to take them seriously, and to take care of them promptly.

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